The Nurse Is Preparing to Assess an Adult Client Who

The nurse is preparing to assess an adult client who presents to the emergency department (ED) after falling down some steps at home. The client complains of left ankle pain and has open abrasions to the left knee and shin. Which should the nurse incorporate into the physical assessment of this client?

A) Washing hands in the presence of the client.
B) Putting on nonsterile gloves to examine the client.
C) Ensuring that the client has an empty bladder before beginning the physical assessment.
D) Instructing the client to hold all questions and comments until the completion of the assessment so that the nurse can focus on the exam.
E) Assessing only the left lower extremity since this is the injured body part.